Has the quality of public health services changed over recent years? This is the question posed in the latest QualityWatch report from the Nuffield Trust and the Health Foundation, which addresses public health and prevention. This report is to be welcomed, signalling as it does that quality is just as important in public health and prevention as it is in treatment and care.
The report looks at trends and regional differences in 20 indicators of quality across five areas of public health (sexual health, substance misuse, smoking, childhood obesity and immunisations), pulling data from the Public Health Outcomes Framework and elsewhere, supplemented by an online survey of Directors of Public Health to get a more nuanced view of how the public health (and wider) reforms and funding cuts to public health have affected quality.
QualityWatch finds various trends amongst the 20 indicators between 2009 and 2014. Its overall headline messages from these are:
- improving access to contraception but increasing rates of sexually transmitted infections (STIs);
- improved waiting times and treatment completion for some substances but increasing alcohol-related hospital admissions;
- falling smoking rates but a 45% decline in setting a quit date with local stop smoking services between 2012/13 and 2014/15;
- declining obesity in young children (4-5 years) but no change in older children (10-11 years);
- stable immunisations coverage, but further improvement needed in MMR uptake
What are we to make of this? First, is the need for some caution, since some of these trends may have been happening for some time. Indeed, the authors conclude that there is little evidence of marked changes in the quality of services to date. The biggest change here is in the use of local stop smoking services, perhaps more to do with the accelerating use of electronic cigarettes in the population at large, as smoking rates continue to decline.
More informative than the data, at least to date, is the survey of Directors of Public Health (DsPH). The DsPH interviewed were positive about the opportunities the reforms have brought them to work across local government, including much more local flexibility in contracting and commissioning and in bringing a focus on ‘health’ into other services such as housing, transport and leisure. This is very encouraging to hear given this has been widely seen as the key potential benefit of the reforms.
However, the reforms also brought fragmentation as the NHS and local government boundary has been reinforced in some areas. Work at the King’s Fund has brought this into stark relief. Recent hearings into the public health reforms at the Health Select Committee also raised real concerns about NHS data sharing with local government, particularly in vaccination and immunisation.
Given last year’s in-year cut to the Department of Health grant, further planned real terms reductions announced in the Spending Review and the upcoming consultation on switching funding to local business rates, it’s no surprise that the survey shows DsPH are very concerned about the impact on the future coverage and quality of services and the morale and potential loss of the workforce needed to deliver it.
If a broadly successful transition following the reforms is not to be squandered by in-fighting over resources and responsibilities across the NHS-LA boundary, and internal boundaries within the NHS and local government, then a focus on population health needs to become embedded more strongly across the system. That means public health being a central focus in all the place-based planning that is currently (rightly) in vogue. Greater Manchester’s MOU is one model across the NHS and local government, and some including Coventry and Barnsley are becoming “public health councils”. But as one respondent in this research warned, “...the main purpose of transferring public health to local government was to address wider determinants of health and wellbeing. The cuts to general local government budgets make this frankly impossible.”
That’s an important warning, but too pessimistic. Councils have to keep their nerve in difficult times on using all the funds and other means including planning, regulations and using the assets in their communities, to help deliver health gain. They also need the NHS to do its bit and make good on the commitment to prevention and the huge economic and employment power it has in local communities. As I have argued, the NHS needs to wake up to its role in the wider determinants of health - it is not just for councils. Alongside that we now need to see public health featuring much more strongly in ‘NHS’ Sustainability and Transformation Plans, and Health and Wellbeing Boards really stepping up.
If this transpires, then perhaps the next time QualityWatch turns its eye towards public health and prevention it will be in a better position not only to answer the question it poses on whether the quality of services has changed over recent years, but also to tell a really inspiring story of how that has come about. As for now, triangulating the data and findings of this QualityWatch report with the more detailed data on spending choices in public health in local government now available should be a priority if we are to understand how all these factors are leading to change in the quantity and quality of public health services in England.